This presentation will cover a host of ways in which, paradoxically, psychotherapists can compromise the quality of care offered to clients when they adhere to narrow definitions of professional ethics in the everyday world of clinical practice. We psychotherapists have an overarching ethical obligation to practice in ways that enhance client well-being (beneficence) and mitigate any potential for harming clients (nonmaleficence). All too often, psychotherapists approach the task of obtaining informed consent for treatment in medico-legal ways, meeting the risk-management and bureaucratic needs of practitioners, or the institutions they are affiliated with, at a delicate moment early on in therapy when clients want these matters to be of secondary, not primary importance. Maintaining strong professional boundaries is perceived as crucial to preserve the basic structure of therapy. However, so-called “boundary crossings,” such as therapist self-disclosure, the giving and receiving of gifts, and non-sexual physical touch, under certain circumstances, can be invaluable ways of cultivating therapist-client rapport. An overzealous approach to professional boundaries can rationalize what clients experience as off-putting aloofness, coldness, and indifference on the part of their psychotherapist. Practicing with multicultural competence has become elevated as a critically important dimension of professionalism in the field. But, is it enough to simply acquire knowledge of and show respect for diverse races, ethnicities, and identities, or are psychotherapists beckoned to take a bolder approach: namely, working in concert with clients to help them understand and address the myriad ways they are marginalized, oppressed, and minoritized by dominant cultural values? Psychotherapists’ training and education does not come to a grinding halt at licensure. Maintaining and upgrading clinical competency is a professional/ethical mandate. But what are the continuing education implications of mounting evidence showing that clinical effectiveness and favorable treatment outcomes are connected to the personal and interpersonal skills of the psychotherapist? What life pursuits might enlarge and deepen psychotherapists’ personhood in ways that improve their clinical effectiveness? Related to this, if many psychological problems are the result of “moral injuries,” or human wrongdoing as the result of betrayal, deceit, unfairness, exploitation, and the like, do psychotherapists have an ethical obligation to familiarize themselves in deeply personal ways with these aspects of the human condition so as to be of maximum benefit to clients?

This presentation will address these topics and questions in highly practical ways to help participants be more aware of the pitfalls associated with seemingly benign ways of employing professional ethics and the gains that can be yielded in therapeutic effectiveness by prioritizing humanistic ethics of care. Case vignettes will be inserted throughout the presentation to ground research findings and theoretical ideas in a manner that renders them more clinically useful.

Reconfiguring Informed Consent

Although each of the professional organizations that represent master’s and doctoral level psychotherapists have their own slant on what comprises acceptable informed consent procedures, a comprehensive list of what topics practitioners should aspire to is as follows:

• the goals, methods and likely length of treatment;
• psychotherapist’s credentials and pertinent clinical experience;
• expectable benefits and risks to proposed treatment, as well those associated with alternative options, or no treatment at all;
• confidentiality and its limits (e.g., mandated reporting requirements pertaining to child and elder abuse, and “duty to warn”);
• fees and available payment methods;
• limits on treatment posed by third-party insurers;
• policies around cancellation, text and email exchanges, and phone availability between sessions;
• authorization to consult with relevant outside parties (Knapp & Fingerhut, 2024; Pomerantz, 2005; Westin & Rozental, 2024).

Now that most practitioners provide teletherapy sessions, it has even been argued that dutiful informed consent should include a discussion about the potential for breaches in privacy and data security and all the steps psychotherapists are prepared to take to minimize such risks (Luxton et al., 2024).

Professional ethics around informed consent also extend to communicating one’s competence as a practitioner treating clients from a variety of racial and ethnic groups, as well as those who might identify as LGBTQ+ (APA, 2021a). Governing bodies overseeing clinical practice standards imply that psychologists, social workers, and marriage and family therapists have an ethical obligation to enhance client well-being (beneficence) and mitigate potential harm (nonmaleficence) by privileging treatment interventions that have empirical backing when discussing options with clients (APA, 2021a; Blow & Karam, 2017; Drisko & Grady, 2019). Ideally, all this should be covered in a language any given client can reasonably understand and “as early as is feasible in the therapeutic relationship” (Barnett, 2015, p. 3). This is notwithstanding the increasing trend during intake sessions to obtain symptom checklist baseline data from clients for purpose of monitoring progress (Uckelstam et al., 2019).

It can be argued that the potential for conflict between professional and humanistic ethical principles is most acute during the initial stages of psychotherapy, particularly when determining best practices for conducting intake sessions and securing informed consent. One of the most heated conversations with a colleague I have had over the years was with the clinical director of a college counseling center who had cut and dried ideas about how intake sessions should be structured. She was emphatic in her position that for liability reasons the mental health staff she oversaw should front-end contact with clients during intake sessions with a detailed discussion about informed consent and the obtaining of symptom checklist data to assess for self-harm. My counterargument was that this approach ran the risk of leaving many clients feeling alienated, perhaps even mildly betrayed. My logic was that most clients put off seeking psychotherapy until they are in desperate need of help. They show up at the initial therapy session experiencing acute distress, holding out hope that compassionate interest and listening shown by the professional helper they encounter will reassure them that psychotherapy might – after all – be a valuable emotional resource, engendering psychic relief. It seems plausible to assume – unless told otherwise – that the tone and tenor of the initial session will represent in some shape or form what their psychotherapy experience will be like. A type of “bait-and-switch” dynamic may compound any despair they are afflicted with. Expecting care and understanding, they are instead met with a host of impersonal, quasi-medico-legal requirements that shape their first psychotherapy impressions. I more than hinted to the college counseling center director that her practice standards around informed consent, oddly, certainly qualified as ideal for risk management in the professional ethics sense, but could cause unintended emotional harm from the perspective of humanistic ethics.

Thought leaders in the field of medical and mental health ethics underscore how the main purpose of informed consent is to respect the autonomy and self-determination of clients in making thoughtful decisions about treatment options presented to them that offer promise in ameliorating sources of pain and suffering (Beauchamp & Childress, 2019). All too often, a hasty, overzealous, comprehensive, approach to informed consent can meet the bureaucratic, risk-management reduction needs of a practitioner, or the institution within which he or she practices, in ways that discount client agentic preferences. We know from prior research that clients enter treatment wanting discussions about informed consent to occur later in the psychotherapy process (Braaten & Handelsman, 1997). The latest empirical evidence also shows that the vast majority of people seeking psychotherapy (73%) report: “The most valuable aspect of therapy is sharing your thoughts and feelings without feeling judged or ashamed,” and (67%) say “The main goal of therapy is to better understand yourself and the root of your issue” (Delboy & Michaels, 2025). In this study only 29% of would-be clients surveyed endorsed the statement: “One of the most important factors for me choosing a therapist is that the therapy provided is evidence-based.” Humanistic ethics privilege how due consideration must be given to the timing and content of informed consent requirements in ways that front-end psychotherapy with the foundation in relational sensitivity clients need and prefer. Scholars studying premature dropout in psychotherapy are often mystified by the high rates of clients who fail to return after the first visit – between 20% and 50% (Schwartz, 2022). It is surprising that there is scant focus on how formal intake requirements around informed consent may be off-putting to many clients, giving them the impression that psychotherapy is strictly a scientific-medico-legal endeavor rather than the attentive, caring, and emotionally inviting endeavor they are inclined to believe it should be. The upshot for all too many would-be clients might be that a premature focus on formal intake requirements deprives them of the sort of caring and careful listening they expected from therapy, causing them not to return.

Trainees and early-career mental health professionals working in clinics, counseling centers, and hospitals under close supervision are often compelled to prioritize informed consent protocols and electronically input clinical information during intake sessions. When meeting with a client for the first time their attention can be easily monopolized by the need to check off all the risk-management steps imposed by the institutions they work in, as well as collect data required by third-party payors. Meanwhile they are compelled to convert the book knowledge they have acquired in the classroom into applied knowledge in the therapy office. The pressure trainees and early-career professionals are under to meet high standards of professional ethics and clinical competency can be immense. The following disclosure by Matthew Liebman, completing his pre-doctoral internship at Montefiore Medical Center in the Bronx, New York is all too typical:

In graduate school it is easy to forget that everything you learn has to do with people. None of the theory is any good unless it can be applied to helping people in need. And when that person is sitting in a chair across from you, looking at you with a bizarre mix of depression and hope as if the next thing out of your mouth could potentially have the power to make it all better, the pressure may be enough to shake loose every bit of information you’ve learned in the past several years all at once, creating a flood in your psyche. Alternatively, everything you’ve learned thus far may simply disappear (Knafo et al., 2015, p. 46).

Anxiety around being exquisitely professional, ethical, and faithful to supervisory and institutional protocols, raises a susceptibility for trainees and early-career professionals to be overly formal and performative in ways that render them ill-attuned to the in-the-moment emotional needs of clients. It has always seemed both ironic and sad to me how misguided it is when beginning therapists slide into a conventional, bureaucratic mindset at any hint of suicidal thoughts mentioned by clients to secure a no-suicide contract. Not only does this potentially short-circuit any meaningful discussion about feelings of helplessness and despair clients may be experiencing, or hope for a better life than the miserable one they are living, it weakens any connection clients might have with the therapist whereby they develop a sense of human accountability to him or her in ways that might motivate honoring any no-suicide contract that is secured.

It is important to remind ourselves that common standards of informed consent derive from the medical establishment and tend not to map neatly onto what is appropriate in the mental health field (Knapp & Fingerhut, 2024). In the world of medicine, it is possible to speak with precision and clarity about types of procedures and their likely outcomes and use scientific evidence to opine about risks and benefits. For those psychotherapists who subscribe to employing formulaic evidence-based interventions in their work, citing data to back up their efficacy, informed consent discussions with clients are more likely to parallel those in the medical field. Circumscribed techniques can be readily defined, and insofar as symptom reduction is the desired outcome, progress can be straightforwardly identified and monitored.

Evidence-based treatments may be appropriate for clients who present with discreet problems, like specific phobias, or a clear-cut diagnosis, rendering informed consent discussions about the nature and length of treatment more streamlined. But, what about the bulk of clients who seek psychotherapy who live complicated lives, who are afflicted by – and afflict others – with difficult personality traits, and who complain of a range of symptoms cutting across a variety diagnostic entities? Or, whose goals for therapy reach beyond mere symptom reduction and are more subjective and amorphous, though virtuous and meaningful: “I want to feel more in control in my life … understand why I keep being attracted to the wrong type of men … feel more hopeful about the future … be less reactive with my kids … be capable of falling in love.”

Some recent data substantiate that most people who pursue psychotherapy hope to obtain changes in their overall sense of well-being (O’Callaghan et al., 2023). When participants were asked, What do you expect to get out of therapy? the most common answers were:

• “Letting go of feelings I’ve been holding onto;”

• “A breakthrough that leads to feeling better;”

• “Long-term support;”

• “New skills;” and

• “My problems to be fixed.”

Also, the top answers to the question, What factors do you consider when thinking about a good therapist fit? were, in rank order:

• “Areas of expertise;”

• “Years of experience;”

• “Personal connection;”

• “Warmth and empathy;” and

• “Commitment to me getting better.”

Interestingly enough, 35% believed that psychotherapy should be open-ended, or last indefinitely. This begs the question, what should the scope of informed consent discussions be with the typical client who shows up for psychotherapy seeking an experienced, warm and empathetic psychotherapist they can enter into an ongoing supportive relationship with that inspires optimism about interpersonal skill building and personal transformation? Keep in mind that honoring client preferences is considered an “ethical imperative” in the mental health field and is associated with lower psychotherapy dropout (Cooper et al., 2022).

First, we can deduce from this set of expectations that it is the interventionist more than the interventions, and the quality of the relationship offered more than any techniques utilized, that are of relevance. Hence, for any meaningful informed consent to occur, the client would have to directly experience what the psychotherapist and psychotherapy offer in order to be adequately informed about what they are consenting to. The quality of the psychotherapist’s procedural knowledge – therapeutic know-how, or embodied experience and expertise – is the service that is being offered. Therefore, ethically speaking, for meaningful informed consent to occur, clients would need to be appraised of this, preferably during any initial phone contact:

I’m happy to tell you about my training, therapy orientation, and years of experience, or you could look it up on my website, but, candidly, it makes the most sense for us to schedule a consult so you can directly experience how I operate in therapy – given the nature of the problems you have – that way you can make your best judgment whether or not it makes sense for you to commit to therapy with me.

The implication here is that an intake session must encapsulate a concentrated and authentic version of how the therapist typically conducts him or herself, so the client directly experiences what psychotherapy avails, in order for he or she to be sufficiently informed about what is being consented to. This is in contradistinction to “highly professional” intake sessions dominated by detailed discussions about “therapy in the abstract,” treatment plans, office policies, confidentiality and its limits and so forth, which deprive clients of a fuller, embodied representation of the type and quality of psychotherapy they might expect. Which is not to say that discussions of office policies, confidentiality, and so forth are not important. Wise clinical judgment and human sensitivity apply here as to the timing of this discussion, what issues are really relevant to the client’s life situation, and whether they are explored in detail or simply referred to in passing as part of a written consent form.

As for conversations about the limits to confidentiality posed by mandated reporting obligations around elder and child abuse, it is important to remember that for the majority of clients seeking psychotherapy this is irrelevant to their life situation, and if the therapist belabors the point, he or she risks conveying to clients a sense of professional rigidity that can interfere with clients’ need for personalized empathic understanding. Under these conditions I typically refer clients to my informed consent form which I have them sign after a few visits have transpired:

Of course, what we talk about in therapy remains private and confidential. That said, there are some exceptions in cases of abuse of children and elders, and other extreme situations, where my mandated reporting obligations might kick in, but I have no reason to believe right now that applies to you.

As regards conversations about treatment planning and anticipated length of treatment, so much depends on the clinical setting in which the psychotherapist works, specific institutional requirements, and accountability to third-party payment stakeholders. The current treatment zeitgeist in the Veteran’s Administration, clinics affiliated with academic settings, and community mental health centers tend to favor evidence-based interventions that are short-term, symptom-reduction focused, technique-oriented, and protocol-driven (Gnaulati, 2022). However, it is worth noting that the American Psychological Association (APA, 2002) in its Criteria for Evaluating Treatment Guidelines has gone on record to caution health care organizations, government agencies, and public policy entities against exclusively endorsing evidence-based treatments that are short-term, diagnostically focused, technically implemented, and less costly to administer. A careful read of this document reveals that the APA endorses a much broader definition of what constitutes evidence-based psychotherapy to include the importance of a strong therapeutic relationship, individual client needs and preferences, long-term treatments whose benefits have enduring effects (despite being more costly), and client progress defined in terms of enhanced quality of life and subjective well-being. And, the APA Ethics Code (2017) remains relatively neutral on the subject of urging clinicians to employ evidence-based treatments and leaves the door open for them to assume a stance that leans on clinical judgment:

Psychologists are committed to increasing scientific and professional knowledge of behavior and people’s understanding of themselves and others and to the use of such knowledge to improve the conditions of individuals, organizations, and society (p.3).

Consequently, even in clinics and institutions where meticulous treatment plans and electronic symptom data collection and progress monitoring are valorized, it is within the purview of clinicians to stand their ground for both scientific and humanistic reasons and see these more in terms of bureaucratic requirements that need to be expeditiously handled as a sideline to psychotherapy, while busying themselves trying to make an emotional connection with clients and talking about goals and progress in the organically occurring ways that might better get psychotherapy off the ground.

As a sidenote, at the onset of psychotherapy, as well as when it is well underway, it is always worthwhile considering whether the allocation of time and energy meted out to painstakingly document treatment goals and outcomes takes away from more healing time and energy spent in the direct provision of care. Tracking goals and progress need not be perceived and handled as a time-consuming actuarial, administrative task cutting into available time spent engaging with a client. Goals and progress can be handled organically in the form of conversational exchanges that arise spontaneously when the content of what the client brings into therapy makes such topics relevant:

Based on what you just said, it sure seems like you have turned a corner being able to be assertive and stand up to your mother when she intrusively takes charge and forgets you are her adult son, not her child son.

This seems to me to be an example of how you are getting better at being your own judge of the quality of your music, rather than feeling at the whims and mercy of outside judgement.

This is exactly what we discussed several months ago! You seem to do much better socially when you are in a committed relationship with a woman who becomes your best friend, and piggy-back off her friendships to form a social life!

Rather than wait to be called upon in class, you raised your hand and spoke up! That, with the other things you mentioned this morning makes me think you are becoming less shy and avoidant. What do you think?

The anxiety you feel around not wanting to turn out like your cousin, waiting tables at age 28, with a kid to support, seems like a healthy anxiety to me! A motivator to stay ambitious and committed to your career goals. What do you think?

I was watching the two of you about to get defensive and go on the counterattack. Instead, you were able to hit the pause button and manifest some acknowledgement of each other’s point of view. Pretty good stuff!

This is notwithstanding how when therapy is chugging along and it clear from the client’s presentation in the room and the content of his or her verbal disclosures that positive changes are emerging and taking hold, client progress is implicit. Progress does not always need to be made conscious and verbally explicit in order for it to be real.

For those clients who want to know up front how long psychotherapy might last, it important to help them differentiate between parameters imposed by finances, insurance coverage, and institutional expectations, versus what duration they actually need in order to obtain meaningful and lasting change. For the benefit of the reader who by choice or institutional mandate restricts themselves to practicing short-term evidence-based interventions focused on reducing symptoms, there are underlying ethical issues surrounding saying upfront with any confidence that treatment will be short and effective. There are a variety of thorny ethical issues inherent in defining client progress in terms of numerical cut-offs in symptom reduction measured over a brief period. First, given that client symptoms fluctuate over time based on any number of life circumstances, any measure of progress over the short run falls short of being a meaningful indicator of sustained recovery. Along these lines, meta-analytic data show that 29% of clinically depressed patients relapse within a year, and 54% within two years after receiving short-term, cognitive-behavioral type interventions (Vittengl et al., 2007). Re-analysis of the landmark National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program data set also revealed that a mere 24% of depressed patients receiving short-term EBTs demonstrated sustained recovery at the 18-month follow-up period (Shedler, 2018).

Additionally, relying on symptom reduction as an exclusive measure of client progress shunts the focus off changes in difficult personality traits, insecure attachment patterns, and emotional defensiveness many clients suffer from, whose improvement paves the way for lasting optimal psychological health (Gnaulati, 2022). Proponents of short-term, solution-focused, manualized treatments assume that they are effective with circumscribed psychiatric disorders even when there are co-existing difficult personality traits, defense mechanisms, or dysfunctional relationship predispositions (Westen et al., 2004). This oversimplifies matters, since for many clients such underlying factors are the deeper cause of their psychological malaise and have to be therapeutically addressed for any meaningful, enduring change to take hold. It is worth mentioning that estimates show that 40% to 50% of clients with generalized anxiety disorder meet the criteria for a diagnosable personality disorder (Newman, 2000; Zimmerman et al., 2005). Also, it is estimated that more than 36% of clients entering psychotherapy embody insecure attachment styles that adversely impact their interpersonal functioning and overall emotional well-being (Ravitz et al., 2010).

When difficult personality traits and problematic social and emotional styles go untreated, many clients are susceptible to persistent anxiety and depression in their lives. In order for there to be lasting relief from disabling feelings of anxiety and depression, such clients need ready availability of long-term psychotherapy aimed at altering the underlying personality and emotional dynamics that give rise to such symptoms. Of relevance here are findings showing how long-term psychotherapy (up to 240 weekly sessions of psychoanalytic psychotherapy and 60 sessions of CBT) aimed at improvements in personality functioning have been associated with stable gains in reduced levels of clinical depression at three-year follow-up (Huber et al., 2017). Another outcome study monitoring the progress of twenty-one clients in psychoanalytic psychotherapy over a five-year time period discovered that it takes approximately two and a half years to enduringly alter the emotional defensiveness--denial, repression, avoidance of painful emotions – underlying clients’ anxiety and depression (Perry & Bond, 2012).

This is notwithstanding how optimal psychological health extends beyond lasting reduction in anxiety and depression, or less emotional defensiveness. Let’s address the question of lasting recovery from depression. Any dedicated psychotherapist or motivated client would be hard pressed to settle for reductions in pessimism, hopelessness, and fatigue, as signaling the end point of therapy, but rather, the enduring presence of optimism, hopefulness, and enthusiasm.

In the last analysis, any meaningful discussion of informed consent around the length of therapy probably needs to incorporate questions about what clients ideally want to achieve from it in terms of their overall emotional well-being, quality of life, and relational effectiveness in the context of what their insurance covers, what their budget affords, and what adjustments psychotherapists are willing to make regarding their customary fees to make any longer model of care affordable.

Boundary Crossings or Alliance Building Gestures?

It is common knowledge in the mental health field that psychotherapists have an ethical duty to maintain strong professional boundaries. They carry the responsibility for ensuring that the basic structure of therapy is preserved in order to optimize the primary agenda of putting their expertise to full use to enhance the well-being of clients. The axiom psychotherapists have a professional/ethical duty to abide by is one where the focus of the relationship is the welfare of the client, not the psychotherapist. At an overarching level, to state the obvious, the psychotherapist is in the role of helper, and clients are there to be helped. Maintaining boundaries around this arrangement is the practitioner’s responsibility. That way clients can safely and confidently settle into disclosing what troubles them without having to concern themselves about the needs of the psychotherapist.

So called, “boundary crossings” occur when psychotherapists find themselves deviating from typical standards of clinical practice that risk sending confusing messages to clients about the nature of the clinician-client relationship. Or, defined more generically: “Boundary crossings refer to any activity that moves psychologists away from a strictly neutral position with their patients (Knapp et al., 2013, p. 82). Common types of boundary crossings include self-disclosure and expressions of personal emotion on the part of psychotherapists; receiving or exchanging gifts; non-sexual, socially appropriate physical contact; making a home visit (i.e., with an agoraphobic or medically compromised client); accompanying a client to an important medical appointment that would otherwise have been avoided; or attending a pivotal event or celebration in a client’s life, like a graduation or wedding. The main underlying ethical concerns are that boundary crossings supposedly compromise the professionalism of the psychotherapist-client arrangement insofar as the practitioner is potentially putting his or her interests and needs before those of the client and acting in ways that clients might construe as constitutive of a friendship. This raises the specter of entering a dual relationship with clients, or jointly playing the role of friend and psychotherapist, the former believed to compromise the professional objectivity of the latter – a potential violation of Standard 3.05 Multiple Relationships of the APA Ethics Code (APA, 2017).

Given these ethical pitfalls, many psychotherapists cleave to strict boundaries and refrain from engaging in self-disclosure, giving or receiving gifts, and so forth. But, what about the ethical pitfalls – at a purely human level – associated with rigid adherence to professional boundaries that clients may experience as bureaucratically rationalized forms of aloofness, coldness, and indifference? Or, what if certain boundary crossings, under certain conditions, with certain clients, are unique and invaluable ways of showing genuine regard for clients while simultaneously strengthening the treatment alliance in ways that bode well for client progress? In a sense, this would require reformulating our ideas about what it means to act professionally based on the notion that we can be friendly toward clients without wanting to be their friends, or playing into their friendship fantasies, and that we can be personable, tangibly supportive, and approachable in non-seductive, non-exploitable ways that put clients at ease. Let me cover three boundary crossing concerns – gift giving and exchanging, therapist self-disclosure, and nonsexual physical touch – where professional and human ethics often collide.

Gift Giving and Exchanging

Receiving and giving gifts from and to clients pose many dilemmas for psychotherapists conscientious about professional boundaries. On the one hand, there is the school of thought that psychotherapists should politely refrain from receiving gifts from clients and instead explore the underlying motives surrounding the gesture. This position maintains an unambiguous, strict line between a professional and a friendship relationship and reinforces the central agenda of psychotherapy being exploring and understanding fantasies, feelings, and motives. Additionally, it circumvents the potential for any “slippery slope” phenomena where any single gift giving or receiving event sets precedent for psychotherapists to become complacent over time and enact more serious boundary violations (Gutheil & Gabbard, 1993). On the other hand, there is a different school of thought claiming that, at a purely human level, gift giving and receiving is a time-honored way that people express gratitude, appreciation, altruism, and affection, and more often than not, when clients or therapists offer gifts, the main purpose is to express these benign virtues (Zur, 2007a). Usually, the outcome is beneficial for strengthening the therapeutic alliance (Knox et al., 2009).

Under what conditions and for what reasons might psychotherapists give or receive gifts adhering to the ethical principles of beneficence and nonmaleficence, given these seemingly discordant positions? Put less technically, what rules of thumb can psychotherapists follow as it involves the giving and getting of gifts to maximize the well-being of and minimize any potential for harming clients?

There is general agreement that questions come into play around gift giving based on various factors such as the timing, frequency, lavishness, and subjective meaning involved. It is rare that red flags flap when gifts are exchanged upon termination of treatment, return from holidays (e.g., souvenirs), or to honor a milestone in a client’s life (e.g., wedding, promotion, graduation). However, if a client is disposed to gift a therapist outside of these more common occurrences, especially if it becomes habitual, there is more reason to explore the subjective meaning of this with the client, whether or not the gifts are accepted or declined. The same is true if the timing of a gift coincides with a particularly difficult or standout treatment session. Questions arise under these gift-offering circumstances of possible indirect ways a client may be trying to please, seduce, or influence the clinician in self-serving ways, or avoid or gloss over thorny issues. When lavish gifts are offered, there is more of a trend in the field to decline since the consequence is often one of psychotherapists feeling obligated to clients, or predisposed to placate or appease in return, rather than free to challenge them in potentially confrontational ways (Knapp & Fingerhut, 2024).

One final thought on gift giving to clients pertains to when an item of special symbolic meaning is offered as a reward for the attainment of an important therapeutic goal. Child therapists often strike deals with their young clients around behavior goals where the prize is more likely to have personal appeal than symbolic meaning. Such a model with adult clients, of course, has a strong potential to be experienced as infantilizing. But, in my experience, when the promised reward carries symbolic meaning, it can galvanize motivation to achieve an important therapeutic goal and strengthen psychotherapist-client rapport. A clinical case example is worth mentioning to dramatize what I have in mind here.

45-year-old Jasmine was seeing me due to a susceptibility to bouts of explosive rage, where she would engage in yelling and name-calling with her partner, Roberto. He was in the habit of withdrawing and shutting down in reaction, or stonewalling, when Jasmine recovered and remorsefully approached him, offering apologies. During one session, Jasmine commented on a print hung on my wall depicting a tree standing tall and strong in the face of strong headwinds. She asked why I chose to display this print in my office and where I had purchased it. I mentioned that the print represented for me the human struggle to maintain integrity and dignity in the face of overwhelming emotions. We both smiled together as I confessed that this was a struggle for me, and, obviously, for her. Rather spontaneously, I said to Jasmine: “I tell you what. Given how arduous it is for you to regulate the intensity of your anger and be assertive, instead of aggressive, when you are frustrated, how about I reward you with this print if you can get better at this over the next few months? I’d be happy to give this print over to you if you make strides here!” Jasmine took me up on my offer. Several months later, after a long spell of greater anger modulation in her marriage, I took the print off my wall and handed it to her. We hugged as we exchanged expressions of pride and gratitude. The thematic content of the print seemed to give it symbolic value for Jasmine and energize her motivation to stay focused on a treatment goal.

Therapist Self-Disclosure

One type of self-disclosure on the part of psychotherapists that is more common than we realize, though seemingly taboo to discuss in professional circles or conduct research on, is crying in front of clients. Some evidence suggests that up to 87% of psychotherapists report having cried at least once in the presence of a client (t’ Lam et al., 2018). There is no rule book to fall back upon as regards whether or not to suppress tears that well up while listening to clients’ heartfelt disclosures. Professional norms are such that by conspicuously crying, psychotherapists leave themselves open to being perceived by clients as lacking composure and competence (van de Ven et al., 2017). Yet, as with other forms of self-disclosure, the intentionality of the psychotherapist, how his or her tears are framed and subsequently dialogued about, and the quality of the pre-existing alliance between client and psychotherapist all play a factor in whether the tearfulness is a boundary crossing of a helpful or unhelpful nature. There is a qualitative difference between clients feeling impinged upon by witnessing their psychotherapist crying in ways that break the flow of their disclosures and shunts them into the role of helper, rather than helped, compared with clients feeling more deeply understood and recognized – a true moment of meeting – because their psychotherapist’s tears convey genuine emotional resonance and caring. In many ways, the latter, more favorable outcome pivots on how able a psychotherapist is under these conditions to be open to and articulate the intersubjective implications of his or her tears as far as clarifying or deepening what clients are experiencing. A clinical example might elucidate.

Several years into therapy, 54-year-old Cameron, found himself revisiting the emotional pain associated with being raised by a father who was overtly dismissive of his achievements, harsh, unapproachable, and void of affection. After being kicked out of the house at age fifteen due to a minor incident, Cameron lived with various friends whose parents saw the good in him and offered their support. He eventually put himself through college, became a successful entertainment lawyer and was happily married with two teenage sons whom he adored. All his free time was spent striving to be the best father possible, guarding against acting like his father and drawing sustenance from the parental role modeling obtained from his friend’s parents.

In the middle of a session, Cameron began tearing up sharing how confusing it was to him that he had been capable of overriding the harsh fathering he had experienced as a child to manifest affection and support with his sons. He surmised this was due to his friend’s parents who had intervened at a critical juncture in his life and kept him from taking a dreadful self-destructive path. I started tearing up myself and mentioned something along the lines of: “In my mind, Cameron, maybe you should categorize you breaking this intergeneration pattern of harsh fathering as a proud life achievement and count yourself fortunate that you encountered some loving surrogate parents when you desperately needed them. “

My quiet tears turned to outright sobbing, and I added: “I guess I’m saying this because you and I have more in common than you think. I also had a father who was brutal and unaffectionate, and were it not for key mentors stepping in at critical times in my life, like you experienced, I would be a shell of the person I am. I also have striven all my adult life to break this cycle with my own son.”

Cameron and I both began to weep, stood up together and hugged each other. It was towards the end of the session and he expressed his deep gratitude toward me that I had made myself vulnerable and shared these aspects of my life with him. He went on to say that therapy for him was so life affirming, a counterforce to the emotional desert of entertainment law that consumed so much of his soul, and that he could not remember one single session in our years together that he had left without feeling nourished and grounded. I responded: “You have been devoted to therapy since the outset, Cameron, pushing yourself to face so much ugliness from the past, and determined to be the best father and husband possible. Thanks for letting me know that you benefit from whatever expertise I have to offer. Together we have built a strong therapy relationship and I’m so glad about that!”

Some relevant research substantiates the therapeutic benefit of the type of emotional exchanges characteristic of that illustrated between myself and Cameron. McCormac and colleagues (2019) discovered that psychotherapists who were prone to make “me too” disclosures – or speak up about their own similar experiences with a psychological concern – received high favorability ratings from clients. That is, if the disclosures were “moderately extensive,” or uttered relatively succinctly, stayed on point, and corresponded accurately and poignantly with the same issue clients disclosed. Some evidence suggests also that “me too,” type disclosures are more efficacious for psychotherapy when in reality they are “me too, a long time ago” disclosures, not shared examples of issues in common that the psychotherapist recently underwent (Moody et al., 2021). Presumably, this is the case because clients assume if there is temporal distance involved the psychotherapist will have achieved resolution over the issue with the passage of time and can speak with some wisdom about it. Moreover, there are burgeoning data supporting how “dyadic synchrony” is a vital component of effective psychotherapy (Bar-Kalifa et al., 2023). In other words, when client and psychotherapist are in sync, co-experiencing a similar hurtful emotional experience, the client’s capacity to maintain, deepen, and self-regulate contact with these feelings is contingent upon the therapist’s nuanced ability to remain attuned to and expressively draw out and elaborate upon what the client is experiencing. In short, emotionally charged, tearful self-disclosures on the part of the psychotherapist need not be thought of exclusively in terms of unfavorable “boundary crossings,” and may even represent potent human moments of client-psychotherapist meeting that bode well for treatment (Pye, 2022). That is, if jointly felt emotional synchrony is occurring and the psychotherapist shares just enough to bring him or herself to the in-the-moment encounter, without monopolizing the situation and making him or herself the central focus.

Nonsexual Physical Touch

Despite the vast literature on the healing potential of physical touch across medical and religious traditions (Pandya, 2022; Swade, 2020), the mental health field largely dismisses it as a legitimate type of therapeutic action and positions it mostly as a potential ethical misstep extra worthy of risk management attention (Zur, 2007b). This predicament is due to factors that are both obvious and not so obvious. The obvious ones pertain to the frequency with which nonsexual and sexual touch are conflated and the specter of psychotherapists abusing the power imbalance in the treatment relationship to sexually exploit clients. Even with the most benign intentions, there is a risk that some clients, some of the time, will misconstrue nonsexual touch on the part of the psychotherapist as a sexual overture, rendering the interaction a possible serious ethical violation. The less obvious ones pertain to early attitudes adopted by Freud and his followers about the importance of “analytic abstinence” (Elhami Athar, 2023) for the processing of traumatic experiences. Important developmental needs like sympathetic touch, insofar as it goes ungratified by psychoanalysts, supposedly puts clients in a productive state of frustration, forcing them to recall distressing early childhood deprivations of a similar nature.

There is reason to believe that a taboo against touch in psychotherapy has taken hold and remains robust, even a hallmark of desirable professionalism in the field. The evidence-based ethos that permeates the field of psychotherapy may be more conducive than we want to believe to psychotherapists covertly thinking they should practice like good scientists: showing impartiality, detachedness, and rationality. In one of the only studies of its kind, a survey of psychotherapists conducted by Stenzel and Rupert (2004) discovered that approximately 90% of respondents never or rarely engaged in physical contact with clients, and when it did occur it was in the context of handshakes at the beginning or end of therapy sessions. This begs several questions: Is touch avoided by psychotherapists strictly based on fear of accusations of sexual misconduct and professional disapproval, as distinct from verifiable beliefs that it is nontherapeutic? If we are touch-phobic as psychotherapists, how much are we colluding with blanket tendencies to conflate sexual and nonsexual touch? Does a strict no-touch policy deprive certain clients, under certain conditions, of emotionally reassuring gestures that would otherwise emotionally fuel and enrich the therapy? Since we know that touch is an all-pervasive aspect of humans’ social being (Capelli et al., 2022), by placing it off limits in psychotherapy are we eliminating an important way that humans socially communicate?

We know from the common-factors model of psychotherapy research that the therapeutic stance optimally suited for effective outcomes is more akin to that of a compassionate human than detached scientist. Consequently, consideration must be given to how an openness to demonstrating compassion tactilely is a dimension of the genuineness, emotional presence, and responsiveness, empathy, and positive regard – common factors – across all therapy approaches that clients prefer from psychotherapy (Swan & Heesacker, 2013) and that is predictive of beneficial results (Wampold & Fluckiger, 2023).

Zur (2007b) outlines various types of touch that have their place when working more humanistically with clients:

Ritualistic or socially accepted gestures for greeting and departure – this might take the form of handshakes, an embrace, or a pat on the back upon at the beginning and end of therapy sessions.

Consolation touch – this captures gestures like hugs, handholding, or hands on the shoulders of clients with the intent to comfort during times of grief, sorrow, or distress.

Reassuring touch – this pertains to pats on the back or shoulders, or gentle rubbing of a client’s back for purposes on positive reassurance.

Grounding or reorienting touch – in the context of clients being anxiously overwhelmed or dissociatively “zoned out,” touching their hand, arm, or back can put them in touch with their body to “reground” them.

Another context for embracing clients that warrants consideration involves cases where clients carry around a sense of shameful self-loathing. I have in mind clients who present as painfully self-conscious; define themselves in terms of their perceived life failures; disavow personal talents they possess; shun compliments; avert eye contact because they expect looks of disapproval, if not repulsion, and other forms of embodied shame. Over the years, once a trusting relationship has been built with such clients, well-timed, spontaneous, mutually generated embraces on occasion can have demonstrable de-shaming effects. A heartfelt embrace can be a primal communication to the client that he or she is not repugnant or unlikeable, but, on the contrary, good and likeable. A relevant case vignette should elucidate:

I initiated therapy with 28-year-old Matt after he had dropped out of college and become suicidally depressed. He was the son of professionally successful parents and had two older brothers, both of whom had entered the medical profession. Afflicted with learning differences and attracted to a more bohemian lifestyle, Matt perennially felt that he was the “black sheep of the family.” It was not uncommon for Matt to casually refer to himself as a “bum,” “a loser,” “a good-for-nothing.” Even though his formal education was limited, Matt was highly knowledgeable and articulate, and his interpersonal awareness could match that of any skilled psychotherapist.

During a session several years into therapy Matt excitedly deconstructed for me themes from the book Guns, Germs, and Steel by Jarred Diamond, that he had run across in a used bookstore. I disclosed to him that this was one of my favorite books of all time and that I was impressed by his nuanced and thorough summarization of the book. I felt moved to elaborate: “Matt, once again I am struck by how articulate and well-informed you are! You might envy your brothers who have so much textbook knowledge. But do they have your interpersonal awareness, genuine interest in learning about history, wisdom into the human condition, wry sense of humor, capacity to be a loyal friend? Do you want me to keep going, because I can with all your other likeable qualities!” It was towards the end of the session and Matt got up to leave. I asked if I could give him a hug. He sheepishly said, “sure,” and we engaged in a firm embrace. He teared up and muttered, “I love you bro … ” I replied: “I love you too Matt and think the world of you. I hope you have a good week and I’ll see you same time next week.”

This exchange typifies for me the conditions where psychotherapists might act from a place of genuineness and compassion to confront embodied shame with embodied acceptance and enlarge a client’s shrunken sense of self-worth.

To be fair, there are other contexts in which therapeutic touch is gaining recognition as acceptable in the mental health field such as with psychedelic-assisted therapy (Dvir & Hull, 2024) and with terminal cancer patients (Osgood & Farr, 2025). Of course, this is notwithstanding the different norms that exist cross-culturally for the prevalence and wholesomeness of physical contact (Ruiz, 2014).

Some research suggests that the therapeutic style of many psychotherapists evolves over time in the direction of “informal eclecticism” that reflect an adoption of common factors, like genuineness and positive regard – largely because clients prefer these human qualities in their psychotherapist and pull for them (Behan, 2022). Implicit in this position is the awkward realization that psychotherapists often have to shed their formal training and education to embrace the sort of ethic of care that clients prefer and pull for, and that is also conducive to therapeutic gains. Perhaps the use of therapeutic touch falls in this camp, and if so, the taboo against it in the field needs to be reexamined and its use incorporated more into the training and education of psychotherapists.

New Definitions of Multicultural Competence

Currently, there is a lively debate underway in the mental health field regarding the ethical standards of care that need to be met in order for psychotherapists to consider themselves multiculturally competent. Typically, as reflected in Principle E of the American Psychological Association Ethics Code, Respect for People’s Rights and Dignity (American Psychological Association, 2017), the attainment of multicultural competence is viewed as an ethical issue in that harm can be caused when psychotherapists renege on their duty to be knowledgeable about and respect cultural, individual, and social role differences cutting across characteristics pertaining to age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status. The thinking is that without a broad-based knowledge of what is considered normal, expectable, and socially acceptable ways of being across diverse cultural contexts, psychotherapists are vulnerable to superimposing their own prejudices and biases onto clients in ways that lessen their dignity and worth as persons.

The lively debate I reference centers on whether multicultural competence is attained largely in terms of acquiring knowledge of and showing respect for diversity, or requires a bolder agenda; namely, working in concert with clients to help them understand and address the myriad ways they are marginalized, oppressed, and minoritized by dominant cultural values. Comas-Diaz (2024), a spokesperson for the latter position captures its ethos: “ … multiculturalists go beyond learning and appreciating diversity by examining power relations, opposing systems that maintain injustice, and committing to equity” (p.199).

For psychotherapists of my generation, launched into the field at the end of the last century, acquiring knowledge about and showing respect for diverse cultural orientations often was sufficient to self-identify as multiculturally competent. One was expected to read up, for instance, on the role of filial piety in the Asian American community – the deep cultural obligation to respect and be loyal to one’s parents and elderly family members. When working with clients of Asian descent it was ill-advised to superimpose notions of underdeveloped separation-individuation onto them. This was especially the case concerning second-generation Asian-American young adults who seemed to live a “double life,” acting more Westernized in public, but deferential at home. The culturally sensitive way to think about this was that these young adults were abiding by cultural norms of filial piety, while exercising age-appropriate autonomy adapting to their current life situation – not manifesting thwarted individuation.

Another basic prerequisite for multicultural competence involved therapists examining their own racial or ethnic identity. A red flag for therapists to watch out for was either the overvaluing or devaluing of cultural attitudes and behaviors with which they had been raised. For instance, a Euro-American therapist might idealize the need for adolescents to rebel mightily to establish their own independent identity. He or she might minimize a Latina mother’s complaint that her son is being unacceptably disobedient – based on Latino norms of familismo, respeto, and bien educado, or respectful, deferential, and well-mannered behavior shown toward parents and elders for the collective good of the family (Chen, et. al., 2020). Or, conversely, a Latina therapist might idealize an adolescent’s need to be compliant with parents and minimize a white mother’s complaint that her son is being overly submissive.

On matters of racial prejudice, the mindset was often one of being open to the idea that some clients, some of the time, would experience discrimination based on their racial minority status, which would leave them understandably angry, even enraged, and sensitized to being similarly targeted in the future. Multicultural competence on the part of the therapist entailed accepting that episodic racial discrimination was a societal reality and when clients of color provided relevant evidence, the sensitive thing to do was to honor it and legitimize any resultant anger – not presuppose that these phenomena represented clinical suspiciousness, paranoia, or “anger management problems.”

In recent years, a more radical, nuanced approach to multiculturalism has emerged in the mental health field espousing the notion that racial discrimination is not episodic – the ugly effects of the occasional actions of people who hold racist beliefs – but pervasive in society in ways that cause everyday suffering to people of color (Mullan, 2023; Sue et al., 2023). It presupposes that racism is systemic, or widespread in ways where people of color are marginalized and oppressed by virtue of the color of their skin, in ways both overt and covert. Everyday accommodations to the norms of White society can lead racial and ethnic minority groups to silence and negate themselves, or tone down their own cultural, linguistic, religious, and aesthetic preferences – with dehumanizing effects. Or, in the case of “microaggressions” that call out for a response, to have to exert the energy and face the discomfort of pointing out a transgression that the transgressor seems oblivious to. Let me share a clinical situation from my own practice that, embarrassingly, applies here.

Several years ago, I met with an African American couple who had sought me out to do psychoeducational testing with their 10-year-old son. When it came time to negotiate the fee, I front-loaded my proposal with comments about how I was open to a sliding scale. In my defense, the family attended a local private school that I had a long-standing arrangement with to offer affordable rates for psychoeducational testing services. The father, rightly so, assertively challenged my impulse to offer a sliding scale on the grounds that I was making the assumption that as an African American family they could not afford my full fee. He clarified that he was an emergency room physician at a local hospital, and his wife a partner in a top law firm, adding that it was distressing for him to be put in a position to correct my racist assumption that as a Black man this somehow negated the possibility that he could be a successful professional with ample resources. My attempt to “do good,” by offering a sliding scale fee, turned out in actuality to be a hurtful racist gesture. I was thoroughly embarrassed and regretful, and speedily apologized.

Leading voices in the multicultural movement even contend that core aspects of what constitutes professionalism in the mental health field has racist effects and are oppressive to minority groups (Sue et al., 2024). They point out that objectivism is subscribed to over subjectivism in ways that can be alienating and off-putting to people of color. Mainstream approaches to psychotherapy often teach practitioners to be neutral, unaffected, and distant, as well as to refrain from using ordinary language in favor of clinical terminology in their dealings with clients. These tenets of professionalism can be experienced by people of color as manifestations of aloofness, disrespect, and insincerity (Speight, 2012). Individualistic values that predominate in Western society, prizing autonomy and independence, often infuse the practice of psychotherapy whereby personal agency, responsibility, and choice-making are taken to be universal markers of optimal mental health. This can be alienating for clients from cultures where collectivism is the norm, who value interdependence over independence, deep accountability to family and kin, and joint decision-making (Sue et al., 2022). In the world of clinical practice, it is more common than we want to believe for clients with a collectivist cultural orientation to be considered “pathologically enmeshed,” passive and dependent, and avoidant when it comes to taking personal responsibility (Moussa Rogers, 2022).

For clients underexposed to and unfamiliar with the type of professional consciousness and etiquette displayed by the average mental health professional, normal treatment boundaries can be experienced as forms of interpersonal rejection. Sessions beginning and ending at a certain time, therapists deflecting when asked personal questions, self-disclosure being asymmetrical, fee negotiations, office policies spelled out, and no after-hours contact between therapist and client may all seem like perfectly good examples of professional boundaries in the mental health field. Yet, for subpopulations of clients these can be experienced as sterile and bureaucratic forms of interacting, enormously different from the everyday conditions that are conducive to them opening up emotionally (Mullan, 2023). Much clinical terminology, intended to be short-hand ways for professionals to communicate in informed ways about clients, can be pejorative, harmful, and victim-blaming and -shaming. Mullan (2023) juxtaposes such terminology with dignified alternatives to counteract the potential for harm: maladaptive behaviors/survival strategies; homeless/unsheltered; drug seeking/relief seeking; difficult case/accommodation required; defiant-combative-defensive-resistant/assertive-self-advocating; non-compliant/does not consent; addiction/physical dependence.

On a similar note, use of clinical terminology and psychodiagnostics is typically considered a hallmark sign of professionalism, but when used unselfconsciously in a psychotherapeutic context with people of color it can be off-putting (Mullan, 2023). For instance, in matters of psychological injury and recovery, many African Americans gravitate toward folk beliefs, spiritual consciousness, and ancestral traditions, with attendant idioms and metaphors touching upon suffering and redemption, hope in the face of despair, forgiveness, peace and joy as foundational for any healing journey (Cherry, 2023; Parks, 2003).

Additionally, from a multicultural perspective, many established approaches to understanding trauma, trauma-informed care, and post-traumatic growth in the mental health field often overlook the unique forms of adversity faced by minority groups, as well as the culturally specific ways these groups cope with and recover from such experience. Additionally, through the lens of multiculturalism, many of the accepted ways of thinking about trauma, trauma-informed care, and post-traumatic growth in the mental health field fail to account for the unique forms of adversity and its remediation experienced by minoritized people. Rather than thinking of trauma exclusively as a discreet event occurring at a circumscribed place and time, Adler and Schwaba (2024) propose a dynamic conceptualization of trauma that incorporates intergenerational and ancestral trauma, as well as forms of extreme adversity and systemic oppression affecting marginalized groups, that become a part of the identity of minoritized people. For instance, for Black Americans who have undergone generations of discrimination and oppression, including the horrors of slavery and its aftermath, as well as the adverse effects of systemic racism, any traumas they are afflicted with need to be seen against the backdrop of these traumatic legacies (Ortega-Williams et al., 2024). Any real multicultural, trauma-informed care would have to go beyond a focus on the traumatized individual and identify and address the socio-historical conditions that have proven to be traumatizing.

Relatedly, as it pertains to trauma work with sexual and gender minority persons, Ellis and Wieling (2024) propose an ecological model of post-traumatic growth where recovery and resilience cannot be obtained from individual trauma treatment alone, but necessarily incorporates constructive ties with the LGBTQ+ community, interpersonal relationships with friends and loved ones who counter the effects of discrimination in their lives, and political activism.

Not uncommonly, standard professional boundaries entail psychotherapists restricting themselves to assuming an observational stance, assisting clients with exploring troublesome and troubling trauma-related thoughts and feelings. The implications of Ellis and Wieling’s (2024) ecological model of post-traumatic growth are more far-reaching concerning the stance psychotherapists could assume when working with LGBTQ+ clients. Transformative therapeutic care might extend to psychotherapists being more of a compassionate witness to real-world traumatic discrimination, as distinct from just providing “clinical empathy,” in ways that leave clients feeling convinced that their suffering is not just being listened to, but legitimized. Orange (2016) weighs in here: “To face soul-destroying trauma means – to me – to consider psychotherapeutics as a moral, a humanitarian undertaking” (p.20).

Interventions may periodically tilt in the direction of encouraging real-world action to address real-world traumatizing events and conditions. The therapist may assume a political obligation in concert with clients to take corrective societal action with therapeutic benefits, in all probability, derived from clients being able to effect change in ways that both redress their own legitimate grievance and diminish the chances of others suffering similar insults in the future. Let me unpack a clinical case I was involved in a number of years ago that contains elements of the type of ecologically informed post-traumatic growth in question.

Janice, a 53-year-old public school teacher sought me out in the midst of a life crisis centering on her being under threat of losing her job, and with it, her access to full retirement benefits. During the initial visit, she was on edge and punchy with me, confessing that she saw this session as more of an interview to enable her to make up her own mind whether I, as a male therapist, could adequately understand her life predicament as a lesbian woman. With sincerity, I affirmed that of course she had every right to want reassurance that my maleness would not be an issue and that therapy would be a welcoming place for her as a lesbian woman. My non-defensiveness about “being interviewed” by Janice seemed to win her over and she wasted no time filling me in on the crisis she was undergoing.

Over the span of a few years, Janice had been taunted and harassed by groups of middle school students in the science classes she taught. Janice was not “out” as a lesbian woman either with her students or fellow teachers and preferred to keep this aspect of her personal life private. Certain students pushed the limits, sensing that Janice might not be heterosexual, disrespecting her privacy by making comments like: “Janice, are you a tomboy … do you like/hate men … why do you never wear a dress … have you ever gone on a date?” Janice, who did not enter the teaching profession to be a behavior management person but to impart her love of science to students, struggled to set limits around these disrespectful, homophobic transgressions. The taunting and harassment became more hostile. On one occasion, someone threw a dildo through her classroom window which landed feet away from her desk. On several occasions, Janice walked up to her car in the parking lot only to discover that someone had deflated her tires.

Janice complained to school administrators that she was being targeted and harassed by students based on her sexual orientation. Her principal agreed to conduct an observation and sat in during one of her classes. On the day that this occurred, several students at the back of the class were caught smoking marijuana using cored out apples. The principal asked them where the apples had come from. They claimed Janice had passed them out earlier that morning. An investigation was launched, and Janice was put on temporary leave for supposedly aiding and abetting the smoking of marijuana in her classroom. Janice heard through her teacher’s union that the school district was considering taking legal action against her and setting up a case to fire her. Janice was just a few years out from retiring, having been a public school educator for over twenty-two years. Being fired would disqualify her from obtaining a full retirement package, which she was counting on to survive financially as she grew older.

As I listened to Janice’s story, my outrage mounted. I framed her situation in terms of betrayal trauma: having taught for over twenty-two years with the aim of passing along her love of science to students, the school district not only refused to loyally defend her, but by siding with the unmanageable students in her class, was perpetrating victim-blaming. Janice’s anxiety and self-doubt left her half-believing the principal’s narrative that Janice was an inept disciplinarian meriting being fired. I countered strongly with a different narrative; namely, that classroom behavior management might not be her strong suit, but her love of teaching was, and that she might need to keep reminding herself that she was the target of harassment based on her sexual orientation and that institutionalized homophobia might be at play. I strove to take the focus of culpability off her and place it on school officials for not protecting her physical and mental well-being, as well as her privacy rights. I encouraged Janice to strengthen her ties with the teacher’s union, ideally doing some sleuth work to identify people with power there who might be LGBTQ+ friendly, as well as inquire into whether legal representation could be obtained through the teacher’s union.

As the months unfolded Janice seemed to experience my advocacy as instrumental in solidifying her sense of betrayal, which motivated her to take self-defensive action. I helped her apply for disability in a way that would stretch out her employed status and keep her eligible for her full pension should she be approved – which she was. I had conducted psychological testing with her and substantiated her PTSD brought about by sexual orientation harassment as part of the disability claim. These concrete steps seemed to give Janice the reinforcement she needed to solidify the sense that she was subjected to injustices and worthy of redress – in the face of her perennial self-doubt around the seductive counternarrative that she brought all this on herself by not being a better classroom disciplinarian.

Once the urgent matters had been resolved around Janice’s employment situation, leading to her being placed on permanent disability and eligible for full retirement, psychotherapy took on more of a traditional flavor. Janice opted not to countersue the school district and preferred to “let sleeping dogs lie.” We explored whether this choice of hers reflected some form of internalized homophobia, or discomfort around feeling exposed in compromising ways based on her sexual orientation. Janice had expanded her social network with lesbian friends and felt more comfortable “owning” her sexual orientation this way, rather than perceiving the taking of legal action as a possible social correction that might solidify her identity as a lesbian woman. Psychotherapy then freed Janice up to pridefully honor her years of service as teacher, mourn the suboptimal way her career had ended, and address everyday psychological challenges, like adjusting to the lifestyle needs of her extroverted, Type-A, partner and maintaining healthy boundaries with her intrusive elderly mother.

Another area where the prevailing professional/clinical assumptions of psychotherapists are being turned upside down around what constitutes post-traumatic growth, pertains to the possible role of BDSM (bondage, dominance, submission, masochism) sexual practices in ameliorating childhood abuse. BDSM typically refers to sexual activities where power-sharing and consensual experimentation with pain are turned toward eliciting sexual gratification (Brown et al., 2020). The sex lives of those that self-identify as BDSM often encompass activities such as bondage (use of restraints), discipline (promises to abide by certain rules and punishments), dominance (assertions of control), submission (surrendering control), sadism (obtaining pleasure from inflicting control or pain), and masochism (obtaining pleasure from receiving pain, surrendering control, or being subjected to humiliation).

Historically in the mental health field, BDSM sexual practices have been perceived as perverse and pathological, and framed largely as reenactments of childhood abuse where clients unconsciously put themselves in situations that resemble their harmful past, risking revictimization (Brown et al., 2020). This idea stems from Freud’s (1920) notion of the “repetition compulsion,” where people abused as children cling to and reenact what is familiar to them, in their desperate attempt to psychologically manage trauma. They become habituated to the idea that dominance and submission, even violence, is a normative aspect of supposedly loving relationships, in ways that extend to sexual intimacy.

However, survey data do not support any uniform, or tidy categorizations surrounding BDSM sexual inclinations automatically reflecting a history of unresolved childhood maltreatment. Some evidence suggests weak and nonexistent links between childhood maltreatment and gravitation toward BDSM sexual practices (Blizard, 2001; Brown et al., 2020). It is important to add that the norms around bedroom sexual behavior are tilting in a direction that includes mutually consensual rough sex, or what is more commonly called “kink.” Seventy-nine percent of couples in a recent study report incorporating “rough sex” (choking, hair pulling, and spanking) into their intimate lives (Herbenick et al., 2021). And, several years ago, an article in the Archives of Sexual Behavior, investigating the sex lives of over 1,000 individuals, revealed that upwards of 70% found one of the following gestures desirable (while half of the participants found three such gestures desirable): ties me; handcuffs me; pulls my hair; bites me; slaps me; spits on me; talks dirty to me. The authors concluded: “aggressive and humiliating sexual play constitutes a normal variation in sexual desire” (Apostolou & Khalil, 2019, p. 2197).

All said, robust evidence is available identifying links between psychological, physical, and sexual childhood abuse and gravitation toward sadomasochistic sexual practices in adulthood (Abrams et al., 2022), such that when working with clients attracted to BDSM sexual tendencies it is defensible to quietly suspect (though not confidently assume) childhood abuse. The question then becomes whether, or to what extent, are BDSM practices simply traumatic reenactments of childhood abuse involving dissociation and revictimization, or actively revisiting past traumas in playful ways that allow for reprocessing and healing?

Multicultural competence working with people whose BDSM inclinations are an aspect of their personal identity – high rates of which intersect with LGBTQ+ identities (Sprott, 2023) – might take the form of psychotherapists working in collaboration with clients to non-judgmentally explore whether childhood abuse influences their BDSM fantasies and preferences. When they do, various parameters can be introduced to distinguish between healthy and less healthy practices. In cases where clients have some awareness of, or are even deliberately pursuing BDSM practices to rework childhood traumas – what Thomas (2020) refers to as trauma play – indications of healthy approaches can be spelled out and reinforced: clear boundaries around what actions are acceptable and unacceptable to perform; prior and ongoing consent around specific acts; safety and communication underscored; honoring of safe words and signals; immediate stoppage of activities if feelings of discomfort or unsafety arise; and “after care” where all parties involved talk through what has occurred in ways that are emotionally reassuring and bonding (Gewirtz-Meydan et al., 2024). Indications of unhealthy approaches would be lax attitudes around consent, failures in honoring safety words and signals, and dismissiveness around open communication, whereby the spirit of consensual role-playing is lost and the activities pursued become reminiscent of past abuse trauma. Actively engaging clients around differentiating between how BDSM activities align or fail to align with healthy and unhealthy forms of trauma play, arguably becomes a human ethical concern in that it is an attempt to help clients self-protectively avoid retraumatization and revictimization. Such an approach also puts it more psychologically within reach for clients – so inclined – to use BDSM play over time to achieve mastery over past childhood abuse by revisiting them under conditions of control and safety (Cascalheira et al, 2023).

Coming full cycle, what stance should psychotherapists take to preserve key elements of a professional attitude while at the same time showing knowledge of and respect for multicultural differences clients manifest? One point of consensus that probably meets with general agreement is that acquired information alone pertaining to the history, social customs, norms, values, and lifestyle preferences of any distinct subculture is insufficient to meet evolved standards in the field regarding what it means to be multiculturally sensitive. Fowers and Davidov (2006) reinforce this point: “No amount of knowledge by itself is sufficient for cultural competence without action” (p. 587), adding, “ … cultural competence frequently requires significant personal transformation, shifts in self-understanding, and changes in motivation and affect regarding cultural issues” (p. 588). In other words, multicultural sensitivity requires more from us than book learning and didactic instruction regarding diversity, equity, and inclusion, or mere rule-following, and touches more on underlying human growth processes. In particular, a perennial healthy skepticism around how traditional ways of defining a professional attitude or demeanor might be experienced by clients as aloof and uncaring; how one’s cherished views on human nature might reflect White-heteronormative, or ethnocentric bias; embracing a human-ethical commitment to actively refrain from saying or doing things that contribute to members of an oppressed group feeling further oppressed in ways big or small; and most of all, developing the character trait of openness (Hart, 2023). The latter reflects a habit of mind where we strive to honor and respect the otherness of the other, or stay curious about the experiential world of others, even though it appears unfamiliar and unusual to us – all of which guard against the temptation to perceive differences between ourselves and clients as defects in them.

At a purely human level, therapists may need to watch for cultural insularity in their personal lives – living in an “echo chamber,” or assuming a narrow outlook on life and a scaling back in lifestyle choices that subtly reinforce values and attitudes they think are normal for all people. Perhaps more so than in other professions, we have an obligation to build deeper cultural competency by regularly putting ourselves in contact with members of diverse racial and ethnic groups, as well as those whose sexual and gender identity, as well as station in life, differ from our own. By gaining social exposure in this way, there is a greater chance that we will not only feel comfortable in our own skin, but also in the skin of those who embody difference. What I have in mind here is comfort and composure – acquired through life exposure – in the presence of clients whose racial, ethnic, sexual, or gender identities, or combinations of them, differ in significant ways from our own. A therapeutic presence imbued by comfort and composure in the face of clients’ differences are basic for them to not feel othered, or unrelatable. Along these lines, Adrian van Kaam, founder of the Institute of Formative Spirituality at Duquesne University in Pittsburgh, aptly claims: “True therapeutic concern is, at the least, an implicit awareness of the inalienableness of my client’s life” (van Kaam, 2022, p. 29).

In ending, the current multicultural zeitgeist emphasizes prizing the unique experiences of those belonging to and identifying with minoritized groups, bonded by the particular types of oppression they have undergone that are unshared by other groups, especially members of dominant White culture (Comas-Diaz, 2024). This underscores the need for psychotherapists to be open to the true otherness of clients’ life experiences. However, if clients are to be “knowable” and psychotherapists to have emotional inroads to reach and understand them, we cannot lose sight of the overriding aspects of the common humanity that psychotherapists and clients share. At a fundamental level, human suffering takes on universal forms. It is the rare human being who has not been subjected to and is painfully familiar with – to varying degrees – deception, exploitation, betrayal, injustice, and oppression. Psychotherapists may not be privy to, nor share the particular injuries of clients whose identities differ from their own; however, aspects of their experiential world that correspond to the type of suffering clients are undergoing can be tapped into allowing for empathic relatability. In a sense then, psychotherapy can be thought of as an “intercultural encounter” (Guttormsen, 2018), or what Fowers and Davidov (2007) refer to as a type of dialogue where the “indissoluble otherness one finds in those different from oneself” is acknowledged, “ … yet real interchange can only occur because participants in dialogue exercise the cognitive flexibility characteristic of human beings and recognize a shared humanity with the other” (p.706).

Upkeep of Clinical Competency

It is often said that there are as many approaches to psychotherapy as there are individual practitioners in the mental health field. Because of this, it is notoriously difficult to get psychotherapists to reach agreement on what matters most in the profession. However, one area of possible undisputed agreement involves the idea that one’s learning as a psychotherapist does not end upon becoming licensed. Entering the field and learning by doing – reflective practice, acquired experience – may be an important component of professional growth, but it is insufficient to meet general ethical standards of beneficence and nonmaleficence, or promoting well-being and avoiding harm with clients. There are data to back this up. Acquired clinical experience – the more psychotherapists do psychotherapy the better results they obtain – has been found to be a questionable belief (Beutler et al., 2004). It goes without saying that the responsible course of action is to upkeep, expand, and improve upon one’s clinical skills after licensure. This extends beyond any self-generated responsibility on the part of every psychotherapist and is codified in the ethics codes of the various mental health associations. For instance, Section 2 of the APA Ethical Principles of Psychologists and Code of Conduct (2017) under Boundaries of Competence states:

Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experienced, consultation, study, or professional experience (p.5); and,

Psychologists planning to provide services, teach, or conduct research involving populations, areas, techniques, or technologies new to them undertake relevant education, training, supervised experience, consultation, or study (p.5).

The American Association of Marriage and Family Therapy Code of Ethics (2015) and the Code of Ethics of the National Association of Social Workers (2021) contain similar language around practicing only within one’s existing acquired skill set and actively seeking education and training experiences relevant to any new clinical population or entity before offering treatment.

At a basic level, as psychotherapists enter the field of clinical practice more enduringly, and their caseloads expand, so too do the range of clinical phenomena that they need to acquire a working familiarity with. The list can be daunting: crisis intervention around self-harm behaviors and suicidality; sex and pornography addiction; infidelity; conflicts around polyamory; sexual and gender identity issues; childhood sexual abuse; substance abuse; high-conflict romantic partnerships; the premature death of a parent or child; optimal post-divorce co-parenting practices; gambling addition; academic underachievement; imposter syndrome; failure to launch – the list goes on. Referring out due to not having expertise with a given clinical entity can be an important ethical step, but a frequent readiness to take this course of action can hollow out a practice. Therefore, to build a robust practice along ethical lines, it behooves psychotherapists to act fast as regards familiarizing themselves with unfamiliar clinical phenomena that arise. We do not always know in advance what sensitive issues clients will raise. Often, they will only raise them once trust is built, in which case a strong alliance is already in place. Referring out at this point runs the risk of depriving clients of the established therapeutic relationship they may have come to rely upon. Legally and ethically, it might not constitute abandonment to refer out, but at a human level, the client may still feel emotionally abandoned.

Generally speaking, the overall structure in place in the mental health field to facilitate the alternative and advanced clinical learning needs of psychotherapists is one where interventions associated with specific types of therapy (e.g., psychodynamic, cognitive behavioral, and humanistic) are offered to remediate client diagnoses (e.g., PTSD, Borderline Personality Disorder) or clinical features or symptoms of diagnoses (e.g., perfectionism, obsessional thinking, catastrophic thinking, distractibility). For example, as of this writing McLean Hospital in Massachusetts is offering a continuing education course on Mentalization-Based Treatment (MBT) for borderline personality disorder (McLean Hospital, 2025) and the Veterans Administration has an online course titled Navigating Complexities When Delivering EMDR Therapy (US Dept. of Veterans Affairs, 2025). This tailoring of intervention to diagnosable problem has its roots in the medical model where a circumscribed treatment, like a drug or procedure, has a proven scientific track record of remedying an identifiable ailment. However, there is robust evidence challenging the notion that specific psychotherapeutic techniques and interventions are analogs of medical treatments (Nissen-Lie et al., 2023). In the world of medicine, drugs are thought to have effects independent of the provider administering them. In the world of mental health delivery of care, there is abundant evidence that it is problematic to assume that the effects of any intervention or technique can be meaningfully assessed without considering the interpersonal skills of the intervening practitioner (Finsrud et al., 2024). What are the ramifications of this for psychotherapists who, ethically speaking, desire to be maximally effective with a range of clients across a variety of presenting problems?

It would be folly to throw the baby out with the bathwater and call into question the value of conferences, workshops, and continuing education offerings that underscore the acquisition of usable techniques to treat circumscribed symptoms or diagnoses. These are clinical competencies that can add to a psychotherapist’s tool kit, depending upon the client, the presenting problems, the optimal timing of when they should be utilized, and so forth. However, the current zeitgeist is such that many early-career psychotherapists have been saturated with technique-driven, manualized, symptom reduction approaches to psychotherapy and can be overzealous in their use. They try to make the client fit the therapy rather than the therapy fit the client. This type of rigid application of technique can have harmful effects on psychotherapy outcome. In a recent study investigating the reasons surrounding why clients either dropped out of psychotherapy, or felt it failed, one of the top answers given was the inflexibility of the psychotherapist (Alfonsson et al., 2024).

Aponte (2022) sums up how we need to get away from thinking about building clinical competency squarely in terms of the acquisition of new techniques and interventions and zero in more on the personal qualities of the psychotherapist: “The personal self who is the therapist is an essential element of the therapeutic process, because it is the human relationship with clients that is the medium through which the work of therapy is done (p.1).” Based on the research he reviews, he adds: “There is a strong argument that it is the therapist and not the therapy model per se that is more influential in the outcome of the therapeutic process (p. 1).” The concept that it is the interpersonal skills of practitioners – as distinct from how knowledgeable they are about techniques and interventions – that governs how much clients will benefit from psychotherapy is known in the literature as “therapist effects.” As uncomfortable as it is to ponder, therapists can differ greatly in their therapeutic effectiveness, which can lessen or boost what clients can obtain from psychotherapy. Okiishi and colleagues (2003) discovered that effective psychotherapists attained optimal client outcomes at double the rates of those produced by less effective ones.

This is at heart an ethical issue. When we keep notions of beneficence (maximize client well-being) and malfeasance (minimize client suffering) in mind as drivers of desired therapeutic competency, what needs to be more pointedly emphasized in our professional life learning experiences to make us more effective is the cultivation of what Castonguay and his colleagues (2023) call metacompetencies. At a global level, these pertain to the personal qualities and interpersonal capabilities of the psychotherapist. My argument would be, if we are to embrace a higher-order ethical sensibility in our work as psychotherapists, we would strive to reach beyond the mere absorption of knowledge, precise application of techniques and interventions, and commit to a model of professional development where the boundary between one’s personal self-improvement and clinical identity is fluid. Surveys show that seasoned psychotherapists know only too well that their professional growth depends on their personal development (Clark, 2009). It works in the other direction also. Kissil and Nino (2017) found that when early-career mental health professionals used their personhood in psychotherapy, their understanding of relationships in their everyday life was enhanced.

So, what are these metacompetencies that psychotherapists should prioritize and cultivate that are the high-water mark of ethical therapeutic care? Castonguay and colleagues (2023) single out therapist responsiveness as a key metacompetency conducive to favorable therapeutic outcomes (Cacador et al., 2024; Levy Chajmovic & Tishby, 2025). In essence, this is clinical wisdom, or prudence. It comprises a preparedness to be flexible and versatile in one’s approach to each client, tailoring interpretations, interventions, and recommendations to the perceived reality of their life situation, presenting problems, cognitive and emotional styles, and symptom picture – all the while being cognizant of what a client’s psychological make-up allows or disallows as regards the type of psychotherapy offered by the practitioner. Therapist responsiveness demands a sort of eclectic mindset whereby the treatment with a given client is customized. Not an anything-goes approach to psychotherapy, but a willingness on the part of the practitioner to make the therapy fit the client by altering one’s approach. This might mean that a psychodynamic psychotherapist takes more of a directive, cognitive behavioral approach, or a cognitive behavioral psychotherapist incorporates more non-directive, Rogerian empathic listening, for the sake of effectiveness, given the particular needs of a given client. Responsiveness involves when and how to engage a client at the level of affective experience (e.g., “I can tell that what your wife said hurt in ways she seemed unaware of ”) and when and how to engage a client at the level of cognition (e.g., “This interaction with your wife seems to replicate what you told me about how your mother typically acted toward you,” “What gets in the way of you being more assertive with your wife in these moments, shutting down rather than making it clear that her words hurt?”). The timing of when to be supportive, rather than confrontive, directive versus nondirective, communicate verbally as opposed to nonverbally, are also components of therapist responsiveness. The small amount of empirical work available on how psychotherapists might go about building greater responsiveness underscores a variety of attitudes and gestures: heighten one’s awareness of the cues clients manifest regarding the need to adapt interventions to bolster their sense of personal agency and change processes; become more emotionally attuned as a person; commit to greater self-care; and be intentional about trying new ways of interacting with clients and employing different therapy methods, while maintaining strong professional boundaries (Wu & Levitt, 2021).

Therapist metacompetencies have also been tapped by the Facilitative Interpersonal Skills research model spearheaded by Timothy Anderson and his team (Anderson et al., 2016; Perlman et al., 2023). This model identifies a host of therapist characteristics that are conducive to favorable treatment outcomes for clients: verbal fluency, emotional expressiveness, persuasiveness, warmth, positive regard, hopefulness, empathy, and capacity to repair ruptures in the therapeutic relationship. These qualities have been shown to predict the treatment outcomes of practitioners regardless of their theoretical orientation (Anderson et al., 2016). At a more specific level, there is evidence to suggest that psychotherapists’ mastery at recognizing and expressing emotions is key to their effectiveness, perhaps because this enhances their capacity to optimally handle the inevitable ruptures in the client-therapist relationship that arise in most treatments (Gumz et al., 2024).

The upshot is that if psychotherapists are to uphold their ethical duty to advance their skills to be of maximum benefit to the clients they service, there needs to be an ongoing focus on developing their personhood. Historically, one crucible for this to occur is the psychotherapist’s personal therapy. Although this has long been considered essential for entering the field and performing meaningful work with clients, some data indicate that trainees and early-career professionals are shying away from this foundational undertaking (Mix, 2018). It is tempting to wonder if the heavy focus on acquisition of techniques in academia has contributed to this downturn by deemphasizing the valuable effects of psychotherapists’ personal adeptness on their clinical intuition. If so, this is alarming since the psychotherapist’s own therapy remains the single-most important learning platform for performing clinical work (Geller et al., 2005). It is what widens the psychotherapist’s emotional thresholds, familiarizing him or herself with disavowed darker human tendencies and unmet developmental needs. Plunging ourselves into our own therapy primes us to be confidently present and compassionate with clients when they themselves reminisce, grieve, rage, lust, despair, upstage, envy, in ways that explain their emotional unrest. The more self-awareness and emotional integration obtained from their own personal therapy, the stronger the immunity psychotherapists acquire against acting out with clients in ways that do not bode well for the quality of the psychotherapy they offer. Along these lines, there are data supporting how psychotherapists who possess greater emotional intelligence tend to produce better therapy outcomes and lower client drop out rates (Kaplowitz et al., 2011). This is notwithstanding how psychotherapists’ own therapy experience is often the tangible model around which they construct and enact their own formative therapeutic style. This may be why the vast majority of clients prefer seeking treatment from practitioners who have undergone their own psychotherapy (Ivey & Phillips, 2016) and the favorable correlations between the positive therapy alliance that psychotherapists experienced in their own therapy and the successful results of the treatment they provide (Gold et al., 2015).

In essence, it is difficult to imagine how the professional competency of psychotherapists is advanced without a prior or ongoing course of personal therapy that is self-expanding and self-enhancing, viscerally connecting psychotherapists to a greater breadth and depth of human experience that can inform and enrich their work with clients. This prioritizes an ethic of care whereby psychotherapists are given to cultivate personal knowledge toward clinical ends, or ongoingly expand their own humanity since this is their main “instrument,” or experiential pathway to access and understand clients’ sources of agony and ecstasy.

Besides one’s own therapy, what other pursuits might sharpen psychotherapists’ personal and interpersonal awareness in ways that augment their more formal clinical training to render them more effective with clients? One avenue toward this end is the reading of literary fiction. There are robust findings showing that people who are regular readers of literary fiction are less egocentric and more empathic over time, manifest strong social awareness and mentalization capacities, and generally have more complex world views (Castano et al., 2020; Wimmer et al., 2024). Why is this so? The thinking is that engaging with literary fiction sharpens readers’ capacity to put themselves in the mind of characters, identify with the human struggles they grapple with, toss around reasons why characters behave the way they do, or experience the world in the way they do – all the while stretching their capacity to sit with uncertainty and ponder the best and the worst of human motives. Obviously, these are skills emblematic of effective psychotherapists.

Another side-benefit of reading literary fiction for psychotherapists that has relevance for the practice of psychotherapy is the improvement of narrative sensibility. Several decades ago in his compelling article titled the Quasi-Literary Elements in Psychotherapy, (Omer, 1993) likened the enterprise of psychotherapy to that of producing good literary fiction: “The therapist extracts the main storyline from the client’s often jumbled descriptions, detects biases and missing links, and helps the client to change it so as to live better” (p.59). Similarly, Spence (1984) claims: “There is no doubt but that a well-constructed story possesses a kind of narrative truth that is real and immediate and carries an important significance for the process of therapeutic change” (p.21). There is a growing body of research showing that one aspect of effective psychotherapy involves assisting clients with altering their autobiographical narrative, or life story, in ways that are more coherent and reality-based, with interpretative schemas that lessen the disabling confusion they experience (Kramer et al., 2024). The psychotherapist’s provision of plausible explanations for troubling and troublesome experiences endured by a client that have “narrative fit,” or are persuasive, given all the bits and pieces of a client’s life that have been disclosed, assists with a more coherent, believable, confusion-lessening autobiographical narrative. Vaz and Sousa (2024) have gone on record to underscore how the training and education of psychotherapists needs to pivot away from encouraging a neutral, detached, objectivist stance, to embrace a model of working with clients that leverages the psychotherapist’s persuasiveness with regard to offering narrative frameworks whose believability helps clients feel less “demoralized” by their life problems.

Yet another side-benefit of reading literary fiction for psychotherapists is exposure to and familiarization with universal or archetypal struggles that are part of the human condition and underlie the problems in living that clients bring to us. Take a novel like Lord of the Flies about a group of preadolescent boys whose plane goes down on a desert island and they are forced to survive. The elaborate ways in which the decency and decorum of the boys’ behavior deteriorates without adult supervision has relevance to the emotional pain our pre-teen clients reveal caused by playground mean-spiritedness. The Road is a window into the importance of parent-child bonds in the face of adversity; The Sorrows of Young Werther is a treatise on the unbearable agony of unrequited love; Waiting for Godot evocatively confronts us with the folly of always putting off taking action that we know incontrovertibly promises to improve our life, to talk the talk without walking the walk; The Stanger leaves us with a haunting feeling of what it is like to drift through life apathetically and not care to care; Beloved brings to life the traumatic ripple effects of slavery across the generations; Moby Dick puts us in the mind of someone whose narcissistic injury fuels an obsessive desire for revenge; A Clergyman’s Daughter is a complex rendition of a mind governed by dissociation and amnesia; Waiting for the Barbarians is a treatise on how unfounded paranoia can lead to unforgiveable cruelty. Great works of literature often lay out in evocative and textured ways the misery and joy brought about by human vice and virtue. They open up windows into the minds of characters whose problems in living are due to human betrayal, deceit, pride, exploitation, unfairness, or disloyalty. They also open up windows into the minds of characters whose solutions to their problems in living involves courage, loyalty, compassion, fair mindedness, humility, or forgiveness. And, as we shall see in the section to follow, this has relevance for psychotherapists whose care ethics are mobilized when they conceive of psychological problems as moral injuries and psychotherapy as a form of moral healing.

Psychological Problems as Moral Injuries

Moral injury is gaining recognition in the mental health field as a clinical condition worthy of serious consideration. It refers to the emotional distress and trauma, associated with “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs or expectations (Litz et al., 2009, p.696).” The most common morally injurious events that crop up in the research literature are those that occur in the context of military service or combat. They include such phenomena as killing, or causing harm to, enemy combatants or civilians and issuing, or following, orders that result in the injury or death of fellow service members. Recently, other potential sufferers of moral injury have been identified, such as frontline healthcare workers, first-responders, and law enforcement officers in high-stress, even life-and-death, situations.

What separates moral injury from garden-variety posttraumatic stress disorder (PTSD) is that the nature of the trauma is colored by a sense that a person has violated norms of human decency by contributing to, or failing to prevent, serious harm to fellow human beings. Because of this, the person feels dehumanized and haunted by guilt and shame – the awfulness of who they are as a person for having committed, or failed to prevent, the awfulness of bad actions, with awful consequences. Professional standards of care in the field are shifting such that cognitive-behavioral trauma treatments are considered insufficient insufficient, and more humanistic approaches are called for that focus on “moral healing” through deep engagement with moral emotions like guilt and shame, and a therapeutic emphasis on meaning-making and forgiveness (Evans, et al., 2023). A clinical focus on symptom reduction fails to meet the level of human suffering involved – raising questions of ethicality; the restoration of hope, the livability of life, the loosening of cynicism, reasonable self-forgiveness, and risking loving and being loved in return, all being ethical treatment goals commensurate with the level of human suffering involved (Gnaulati, 2019).

The more moral injury is being investigated as a clinical condition, the more we are discovering that not only are feelings of guilt and shame prominent, but also betrayal (Richardson, et al., 2022). In cases where someone has acted deceitfully there may be a dawning awareness of self-betrayal, or deep disappointment and anguish over having violated acceptable standards of good and proper human behavior. In cases where someone has been on the receiving end of a perpetrator’s deceitfulness, there may be a collapse in interpersonal trust, with emotionally devasting, gut-wrenching consequences (e.g., “I felt like my whole world was turned upside down … .like the rug was pulled out from underneath me.”)

For the therapist who is willing to shift sets and listen with a moral sensibility to clients’ sources of personal suffering, it quickly becomes apparent that many, if not most, psychological problems stem from moral injuries – betrayals that can elicit moral emotions like guilt and shame due to being the subject of, or subjected to, human wrongdoing. More generally, the misery associated with acts of deception, exploitation, disloyalty, unfairness, envy, jealousy, and hubristic pride. From a humanistic ethics standpoint this has profound implications because to be of help with clients, we need to return to the original Greek meaning of pathology – pathos, “suffering,” and logia, “discourse or treatise on.” Bodies, brains, or minds do not suffer, persons suffer. To address the root causes of many psychological problems we need to go beyond thinking in terms of symptoms, diagnoses, and their treatment with techniques as the preferred professional course of action, and more humanistically in terms of how to respond to clients who are emotionally reeling because their value system has been assaulted.

Psychological problems – from mild to severe – can be thought of as an accumulation of moral injuries – big and small – that have demoralizing effects on clients. Betrayal in relationships is more common, and its effects more lasting, than we want to believe (Hansson, et al., 1990). More often than not, underlying the idiom of anxiety and depression that clients bring to us are the disheartening effects of everyday betrayals: embarrassing information thought private being shared to others; special achievements and events going unobserved and uncelebrated; unfounded jealousy; broken promises; being disrespected in public; being “ghosted” by friends or romantic partners; deceitful mishandling of money by a trusted partner.

As for ghosting (one-sided ending of communication without notice or explanation), a recent study of undergraduates – largely from underrepresented populations of Black and Latino young adults – found that almost 44 percent% reported being ghosted by a long-term, or new friend, and 37 percent% by a romantic partner or someone they were romantically interested in (Wu & Bamishigbin, 20243). Common reactions were: shock and confusion; self-blame or self-doubt; and, feelings of worthlessness. In the age of social media, being ghosted online is far from psychologically inconsequential. It has been associated with non-suicidal self-injurious behavior (Ding, et al., 2024).

Financial infidelity – conducting oneself financially in ways that would be disapproved of by a romantic partner and deliberately withholding this information from him or her – is also surprisingly common. In a large and robust study of married couples it was discovered that the following behaviors were engaged in at least once: Hiding or lying about spending (85 percent%); creating undisclosed debt (40 percent%); undisclosed gambling (20 percent%); hiding, or lying about, income (20 percent%); and, lying about paying bills/expenses (15 percent%). Since financial infidelity can rival sexual infidelity as a source of relationship harm, and be a leading reason for divorce (Dew et al., 2012), its demoralizing effects are worthy of psychotherapeutic attention.

Professional ethics in the mental health field often mimic those in the medical field, edging the psychotherapist in the direction of objectivity, impartiality, value-free actions. Yet, when we reconceptualize psychological problems in terms of moral injuries, if psychotherapists are to be effective, humanistic ethics become relevant, and psychotherapists need to somehow connect with how a sense of wrongness and wrongdoing might be operating. Tapping into and using their own human-ethical sensibilities is unavoidable. A clinical example might elucidate:

By all accounts, 24-year-old Roberto met all the criteria for a “failure to launch” young man. After high school a brief stint attending community college was cut short by his inconsistent attendance at classes and spotty academic record due to lack of real investment in studying. Roberto lived at home and his parents, both successful professionals, supported him financially. Several attempts to hold down jobs were fruitless due to Roberto oversleeping and calling in sick for specious reasons. Despite periodic upsurges of frustration about him being adrift, that led to urgent demands that he commit to constructive life goals, Roberto’s parents busied themselves with their own careers and mostly left him alone as long as he performed domestic tasks around the house like grocery shopping, walking the dogs, and being on hand for workers showing up to make home repairs. Roberto’s father, a highly successful businessman, seemed to appease his guilt over being absent pursuing his career ambitions by supplying Roberto with ample amounts of money to live off. Roberto kept secret from his father the fact that he used sizeable amounts of this money to fund his drug, alcohol, and gambling habits.

In therapy, Roberto often complained of anxiety attacks and the need for “tools” from me to help him “manage” his anxiety. On those occasions where I asked him to describe his anxiety attacks to me in more detail, they were infused with references to him being unworthy, a “leech,” a “burden,” a “loser.” The clinical dilemma for me was how to stay faithful to the guilt and shame messaging baked into his revelations (that resonated with my naturally occurring feeling that he was behaving guiltily and shamefully), without compounding Roberto’s sense of worthlessness. I started by suggesting to him that underneath it all, perhaps he was suffering from guilt and shame attacks, not anxiety attacks. I sensitively prefaced my remarks: I don’t mean to make you feel worse than you already do … but I wonder if all the guilt and shame you feel over being adrift in your life comes rushing back at times, making you feel awful for bad decisions you and your parents have made over the years? Roberto was not insulted, but deeply curious about this perspective. It led to a series of conversations that were moral in their tone. We discussed everything from the deep shame he carried inside being the son of successful parents, seemingly unable or unwilling to aspire to their success; the wrongness of his father trying to assuage his guilt over being career- driven by “spoiling” Roberto with money; Roberto’s slide into laziness by taking the path of least resistance and avoiding pursuing gainful employment because he did not want for money; and, his guilt over wasting his parent’s hard-earned money on drugs, alcohol and gambling expenses.

I floated the idea that perhaps what Roberto needed in therapy was not tools to manage his anxiety, but deeper conversations about how apologizing and making amends making might be a significant source of peace of mind: Seizing opportunities that might arise with his parents to genuinely apologize for transgressions that haunt him; committing to more responsible spending habits to lessen the guilt he feels over wasting his parent’s money; and, adding to his domestic chores around the house for fairness reasons, or giving back to his parents through contributing more domestically to help balance out the support he received. I added that he might want to think of pursuing talents and employment possibilities more vigorously from a place of self-respect, because in selling himself short by not doing this he ran the risk of fueling the guilt and shame at the core of how he feels about himself. Therapy took on a more productive focus.

In the mental health field, guilt and shame are typically perceived as unproductive emotions that interfere with healthy self-esteem. However, it is worth remembering that appropriate guilt and shame are moral emotional experiences inasmuch as they are psychological ones. They are moral emotional experiences insofar as they have the potential to activate in us the motivational energy to act well and avoid acting badly (Kroll & Egan, 2004). Not uncommonly, therapists tend to view guilt as a toxic emotion. They are often over-sensitized to the psychological effects of too much guilt – of unwarranted guilt – yet often under-sensitized to the interpersonal effects of someone having too little guilt – the absence of guilt when it is warranted.

It is important to remember that among other things, guilt is one of the primary social emotions that keeps people socially aware and appropriately self-conscious. It signals us when we have acted badly and need to make amends to get our relationships back on track.

In the plainspoken words of the philosopher Herant Katchadourian in his mesmerizing book, Guilt: The Bite of Conscience: “guilt makes us feel bad to make things better” (2009 p.72). It realigns the power imbalance that has occurred in relationships due to hurtful actions through the “redistribution of distress.” Knowing that the person who has hurt us feels bad about their actions, and desires to make amends, makes the hurt they have caused us more bearable. Their guilt results in the distress in the relationship being more evenly distributed. It’s not just me feeling bad when she acted badly. They also feel bad for having acted badly, and the pain is shared. In a sense, we feel better by the transgressor feeling worse. The transgressor’s guilt is the emotional catalyst for them to desire to make amends. Knowing that the pain is shared makes us receptive to their reparative gestures.

Guilt can serve a prospective and a retrospective function in bolstering relationships. Feeling guilty as we are about to act badly and potentially harm the relationship makes us hold back and think twice. Prospective, or anticipatory guilt, can be an indication of psychological maturity. It entails a rapid processing of potential interpersonal events: “Oops, if I say this in that way I know I’ll just make her feel bad. Maybe there’s another way of saying it; or, do I need to say it at all?” It’s how psychologically mature people strive to balance honesty with kindness, truth with tact. To be “brutally honest,” as the saying goes, is still to be brutal, to render social feedback useless that might otherwise be useful.

When a person feels guilty after some questionable misdeed, in the best of circumstances, it galvanizes them to want to make things right. Many clients get mired in guilt. They get stuck just passively feeling badly for their transgressions. Just as in the case of Roberto, therapy can raise their awareness of retrospective guilt being a signal for proactive apologizing and amend- making.

Whereas guilt is more likely to be aroused in relation to bad deeds, a person typically feels shame over what such deeds say about his or her overall personhood or character (Madison, 2015). Shame is considered the more agonizing emotion because it is one’s core sense of self – not simply one’s singular actions – that is on the line. If handled well in therapy, whereby the therapist skillfully engenders moral conversations without moralizing, touch upon shame in relatively non-shaming ways, shame can motivate the desire for self-betterment – “I need to change, I simply cannot continue to be that kind of person.”

Shameful betrayals by intimate others, or even by an employer whom a worker has remained loyal to and placed their trust in, can have devastating effects that dismantle values held sacrosanct and upend a person’s overall world view. Such a worker might present as depressed, when the real clinical issue is stifled moral outrage. A past clinical case of mine captures this calamity:

55-year-old Timothy entered therapy at the behest of his wife to treat what ostensibly appeared to be an adjustment disorder, with depression. He complained of “feeling zoned out … lost in his own world … hopeless and uncertain about the future” subsequent to being let go from his place of employment. I asked George to explain to me in as much detail as he saw fit the circumstances surrounding his employment situation ending. Reportedly, George was one of the original executives at a technology startup who had joined with some colleagues to turn it into a thriving business. During its formative years, George had spent endless hours in the business working to attract investors, as well as vetting and cultivating dedicated employees, even taking pay cuts to ensure they were adequately compensated. He was considered “the rain maker” in the company, endearing himself to customers and securing outside contracts by being friendly, reliable, hard-working, and service-oriented. Over the years, George noticed that the colleagues he had originally partnered with developed more of a “bro culture,” playing golf together, going on hunting and fishing trips, and hanging out at a cigar bar, away from the office. George was a self-described “family man” who shunned such activities in favor of spending time at home with his wife and two teenage sons. As the business thrived, there was an executive focus on selling it to the highest bidder, with some of the profits to be allocated among top managers. From out of nowhere, George was notified to meet with a new CEO who had been hired on an interim basis. He was fired and asked to leave the building within a few hours with as many possessions as he could fit in a small cardboard box, with the sterile explanation “the company is heading in a different direction, with a new leadership philosophy whereby your services are no longer needed.” A legal consultation revealed that based on the existing contract George had with the company, he had no legal recourse to challenge the decision. He was offered a generous severance package, but it was a drop in the bucket compared to the monetary payout his colleagues were likely to secure once the company was sold.

Hearing George’s story made me vibrate with a sense of injustice, which infused my responses to him: I can only imagine how betrayed you felt after all those years of being a top performer, giving your heart and soul to the company, believing that as the decent, hard-working, loyal person you are, your dedication would be met with a similar sense of loyalty and decency. My subdued moral outrage ignited George’s real sense that he had been profoundly treated unjustly. My comments along the lines of his depression being a foil for moral shock and outrage resonated deeply with him. Therapy became a relied- upon place and space for him to emotionally process the justifiable anguish and outrage associated with how his years of service ought to have earned him loyalty and generosity in return, not disloyalty and treachery.

Psychotherapy has a drop-out problem that a gravitation toward humanistic ethics by psychotherapists might optimally solve. Although psychotherapy drop- out is difficult to define and measure, accepted rates vary from 20% to 68 % (Doran & DeViva, 2018; Garcia, et al., 2011; Swift & Greenberg, 2014). In a unique investigation covering clients’ opinions as to why they had experienced poor treatment outcomes, causing them to drop out, three therapist-related variables emerged: inadequate assessment/understanding, inflexibility, and poor knowledge (Alfonsson, et al., 2024). Collectively, according to the authors, the unfavorable conditions that can lead to premature drop out can be boiled down to therapists persisting with a conceptualization or treatment model in inflexible ways ill-suited to clients’ descriptions of their problems in ways that leave them painfully misunderstood. In other words, it is possible for psychotherapists to believe they are practicing with the utmost professionalism by remaining faithful to a therapy method or technique that is evidenced-based, and still fail clients based on a lack of openness to take time to acquire deeper, personalized knowledge of what truly ails them. Lomas (1999) claims that when psychotherapists cleave to a fixed way of doing therapy that is technique technique-based they are essentially communicating to clients: “This is how I am going to behave toward you. I hope to do so with sensitivity and compassion, and I will certainly have your good in mind. But I shall stick to this technique, whether you like it or not, because this is how I believe psychotherapy should be done. The matter is not negotiable” (p. 7).

Humanistic ethics privilege favor treating each client as a unique person with a complicated human story to tell who is not reducible to a diagnosis, a symptom cluster, a standard, or a typical case of this or that clinical entity, treatable with identifiable techniques of therapy methods. Rather, the clinical ethos is one of wholeheartedly, and earnestly engaging with a client’s suffering. Miller (2004) hints at why suffering is a neglected concept and point of contact with clients in the mental health field: “To some extent, mental health practitioners are affected by a patient’s suffering in the same way as the patient is: They do not want to feel it. It is painful for most people to observe another human being suffering. The practitioner’s defense mechanisms operate parallel to the patient’s” (p.44). He continues: “ … the morally engaged clinician must always begin by tending to the client’s suffering, in the full sense of that term … this must take precedence over making a diagnosis, defining a treatment plan, or any attempt to change behavior, although ultimately over time, it may lead to all of these” (p. 248).

All in all, ethicality calls for personal openness to suffering brought about by human wrongdoing as a fundamental aspect of a psychotherapist’s professional identity if what they offer are to meets thresholds of relational depth that bode well for treatment outcome (Wilcox & Almasifard, 2023).

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